Why Children with Severe Bacterial Infection Die: A Population–Based Study of Determinants and Consequences of Suboptimal Care with a Special Emphasis on Methodological Issues

<div><p>Introduction</p><p>Suboptimal care is frequent in the management of severe bacterial infection. We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants.</p><p>Methods</p><p>A previously reported population-based confidential enquiry included all children (3 months- 16 years) who died of severe bacterial infection in a French area during a 7-year period. Here, we compared the optimality of the management of these cases to that of pediatric patients who survived a severe bacterial infection during the same period for 6 types of care: seeking medical care by parents, evaluation of sepsis signs and detection of severe disease by a physician, timing and dosage of antibiotic therapy, and timing and dosage of saline bolus. Two independent experts blinded to outcome and final diagnosis evaluated the optimality of these care types. The effect of suboptimal care on survival was analyzed by a logistic regression adjusted on confounding factors identified by a causal diagram. Determinants of suboptimal care were analyzed by multivariate multilevel logistic regression.</p><p>Results</p><p>Suboptimal care was significantly more frequent during early management of the 21 children who died as compared with the 93 survivors: 24% vs 13% (p = 0.003). The most frequent suboptimal care types were delay to seek medical care (20%), under-evaluation of severity by the physician (20%) and delayed antibiotic therapy (24%). Young age (under 1 year) was independently associated with higher risk of suboptimal care, whereas being under the care of a paediatric emergency specialist or a mobile medical unit as compared with a general practitioner was associated with reduced risk.</p><p>Conclusions</p><p>Suboptimal care in the early management of severe bacterial infection had a global independent negative effect on survival. Suboptimal care may be avoided by better training of primary care physicians in the specifics of pediatric medicine.</p></div

Patient characteristics and care pathways before admission to a pediatric intensive care unit, quality of care and their association with outcome by dead and alive children and univariate and multivariate analysis.

<p>aOR, adjusted odds ratio; 95% CI, 95% confidence interval; IQR, interquartile range.</p>§<p>Logistic regression model.</p>a<p>Age and no. of suboptimal care were treated as continuous variables (no deviation to linearity).</p>b<p>Severity signs were hemodynamic failure, purpura, conscientiousness impairment, respiratory distress, meningism, behavioural changes or hypotonia.</p>c<p>Others were 2 pneumonia with pleural effusion and a septic shock following pyelonephritis in a child with malformative uropathy in the deceased group, and 2 septic shock on bacterial cellulitis and a bacterial tracheitis in the survivor group.</p>d<p>Others were, for survivors, <i>Haemophilus influenzae</i> (n = 3), Group B <i>Streptococcus</i> (n = 1), <i>Staphylococcus aureus</i> (n = 1), and for deceased children, <i>E.coli</i> (n = 1), Group A <i>Streptococcus</i> (n = 1), <i>Salmonella spp (n = 1)</i> and <i>Mycoplama pneumoniae</i> (n = 1).</p><p>Patient characteristics and care pathways before admission to a pediatric intensive care unit, quality of care and their association with outcome by dead and alive children and univariate and multivariate analysis.</p

Risk factors for medical suboptimal care.

<p>*Multivariate analysis involved a hierarchical logistic regression model with random intercept and effects.</p><p>**Significant associations remained when age was transformed into polynomials (X = 10/[age – 2.5]), aOR for age 1.04, 95% CI 1.01–1.07, p = 0.003.</p><p>Risk factors for medical suboptimal care.</p